Alameda Alliance for Health Medi-Cal & Alliance Group Care

118 Pages·2017·1.12 MB·English

Provider
Manual
Alameda Alliance for Health
Medi-Cal & Alliance Group Care
March 2018
Call the Alliance Provider Services Department Monday – Friday, 8 am – 5 pm at
510.747.4510. Visit online at www.alamedaalliance.org.
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Table of Contents
Table of Contents ............................................................................................................ 2
Part 1. Alliance Services. .............................................................................................. 6
Section 1: Introduction ............................................................................................... 6
Welcome to Alameda Alliance for Health (Alliance)…………………………………6
The Provider Manual……………………………………………………………………7
Getting Involved…………………………………………………………………………7
Section 2: The Alliance Resources .......................................................................... 12
Alliance Provider Services Department .............................................................. 12
Alliance Member Services Department .............................................................. 12
Section 3: Eligibility and PCP Choice ....................................................................... 14
Identifying Alliance Members .............................................................................. 14
How to Verify Member Eligibility ......................................................................... 16
Provider Portal Instructions................................................................................. 16
Selecting PCPs ................................................................................................... 16
Changing PCPs .................................................................................................. 17
Section 4: Provider Compliance ............................................................................... 18
Alameda Alliance for Health Marketing Materials ............................................... 18
Approved Medi-Cal Marketing Methods ............................................................. 18
Discharging Members ......................................................................................... 18
Part 2. Providing Services .......................................................................................... 19
Section 5: PCP Roles and Responsibilities .............................................................. 19
Primary Care Provider as Primary Case Manager .............................................. 19
Providing Capitated Services to Alliance Group Care Members......................... 21
Non-Capitated Services ...................................................................................... 21
Coordination of Care .......................................................................................... 21
PCP Role in Supervision of Mid-Level Clinicians ................................................ 24
Section 6: Utilization Management ........................................................................... 27
Overview ............................................................................................................ 27
Authorizations Requirements.............................................................................. 28
Radiology Services ............................................................................................. 32

Call the Alliance Provider Services Department Monday – Friday, 8 am – 5 pm at
510.747.4510. Visit online at www.alamedaalliance.org.
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Provider-To-Provider Communication ................................................................ 32
Mental Health Services ....................................................................................... 33
Minor Consent Services ..................................................................................... 35
Vision Care Services .......................................................................................... 35
Hospice Services ................................................................................................ 35
Community-Based Adult Services (CBAS) ......................................................... 36
Section 7: Claims ..................................................................................................... 38
Claims Overview ................................................................................................. 38
Submitting a Claim ............................................................................................. 38
Claims Receipt and Determinations ................................................................... 41
Service Specific Information ............................................................................... 44
Code Sets ........................................................................................................... 46
Section 8: Provider Dispute Resolutions (PDR) ....................................................... 48
Section 9: Service & Referrals for Adults ................................................................. 50
Adult Clinical Preventive Services ...................................................................... 50
Immunizations .................................................................................................... 51
Family Planning Services ................................................................................... 51
Confidential Human Immunodeficiency Virus (HIV) Testing ............................... 53
Abortion Services ............................................................................................... 56
Sterilization Services .......................................................................................... 56
Alcohol Screening, Brief Intervention and Referral to Treatment (SBIRT) .......... 57
Section 10: Services & Referrals for Newborns, Children and Adolescents ............ 58
Newborn Services .............................................................................................. 58
Clinical Preventive Services – Children .............................................................. 59
Immunizations .................................................................................................... 60
Early Periodic Screening Diagnosis and Treatment (EPSDT) Supplemental
Services – Medi-Cal Only ................................................................................... 61
Women, Infants & Children (WIC) ...................................................................... 62
Early Intervention Services ................................................................................. 62
Section 11: Perinatal Services ................................................................................. 64
Perinatal Services ............................................................................................... 64
Reimbursement and Documentation of OB Services ......................................... 67
Section 12: Out-of-Plan Services ............................................................................. 69
California Children Services (CCS) .................................................................... 69
Dental Screening – Medi-Cal .............................................................................. 71
Call the Alliance Provider Services Department Monday – Friday, 8 am – 5 pm at
510.747.4510. Visit online at www.alamedaalliance.org.
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Tuberculosis (TB) Control Services .................................................................... 72
Long-Term Care (Medi-Cal) ............................................................................... 73
Major Organ Transplants (Medi-Cal) .................................................................. 73
Section 13: Health Education ................................................................................... 76
Health Education and Programs ......................................................................... 76
Section 14: Serving Your Diverse Population .......................................................... 77
Documenting Staff Language Proficiency ........................................................... 77
Signage For Interpreter Services ........................................................................ 77
Cultural & Linguistic Provider Training & Development ...................................... 79
Monitoring Cultural & Linguistic Access and Quality of Care .............................. 79
Section 15: Transportation Services ........................................................................ 81
Transportation Benefits ...................................................................................... 81
Section 16: Formulary and Pharmacy Services ....................................................... 83
Pharmacy Benefit Manager (PBM) Services ...................................................... 83
Formulary ........................................................................................................... 83
Pharmacy Prior Authorizations and Exceptions .................................................. 85
Pharmacy Network ............................................................................................. 87
Carve Outs ......................................................................................................... 87
Injectables .......................................................................................................... 88
Section 17: Clinical Laboratory Services .................................................................. 89
Outpatient Laboratory Services .......................................................................... 89
Laboratory Procedures in the PCP Office ........................................................... 90
Part 3. Medical Management ...................................................................................... 91
Section 18: Medical Management ............................................................................ 91
Measuring and Improving Plan Performance (HEDIS) ....................................... 91
Alliance Measures of Provider Performance ...................................................... 91
Care Management Programs ............................................................................. 92
Program Goals ................................................................................................... 92
Interventions Include The Following: .................................................................. 93
Programs ............................................................................................................ 93
Care Planning Coordination ............................................................................... 93
Interventions Include, But Are Not Limited To: ................................................... 93
Transition of Care Program ................................................................................ 94
The Interventions Highlight ................................................................................. 94
Call the Alliance Provider Services Department Monday – Friday, 8 am – 5 pm at
510.747.4510. Visit online at www.alamedaalliance.org.
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Integrated Case Management ............................................................................ 94
Complex Case Management .............................................................................. 95
CCM Criteria Include: ......................................................................................... 95
Disease Management ......................................................................................... 95
How to Refer to Alliance Programs: .................................................................... 96
Reporting Provider-Preventable Conditions ....................................................... 96
Section 19: Grievance and Appeals ......................................................................... 98
Section 20: Credentialing ....................................................................................... 101
Credentialing Process ...................................................................................... 101
BOARD OF GOVERNORS .............................................................................. 102
Credentialing Criteria and Basic Qualifications ................................................. 103
Re-credentialing ............................................................................................... 104
Section 21: Facility Site Review ............................................................................. 105
Facility Site Review Overview........................................................................... 105
Facility Site Reviews ......................................................................................... 106
Medical Record Reviews .................................................................................. 108
Provider Initial Review and Fair Hearing Process ............................................. 109
REQUESTING AN APPEAL ............................................................................. 110
Requirements for Mid-Level Clinicians ............................................................. 110
Organizational Providers .................................................................................. 112
Part 4. Member Rights & Compliance ...................................................................... 113
Section 22: Member Rights and Responsibilities ................................................... 113
Alliance Members Have the Right to: ............................................................... 113
Member Responsibilities .................................................................................. 114
Alameda Alliance for Health Members Have a Responsibility To: .................... 114
How to Protect the PHI of Your Patients ........................................................... 115
Section 23: The Alliance Compliance Programs .................................................... 117
Fraud Prevention Program Overview ............................................................... 117
How to Report Potential Fraud, Waste, and Abuse .......................................... 117

Call the Alliance Provider Services Department Monday – Friday, 8 am – 5 pm at
5 10.747.4510. Visit online at www.alamedaalliance.org.
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Part 1. Alliance Services
Section 1: Introduction
Welcome to Alameda Alliance for Health (Alliance)
Thank you for joining the Alliance provider network! This manual is intended to provide
you with the information needed to navigate our health plan and to assist you with
offering the best possible care to our Alliance members.
ABOUT ALAMEDA ALLIANCE FOR HEALTH
The Alliance is a public, not-for-profit health plan offering high quality managed care to
Alameda County residents. We offer two lines of business, Medi-Cal and In Home
Supportive Services (IHSS) program, also known as Alliance Group Care.
THE ALLIANCE’S MISSION, VISION, & VALUES
The mission of the Alliance is to strive to improve the quality of life of our members and
people throughout our diverse community by collaborating with our provider partners in
delivering high quality, accessible and affordable health care services. As participants of
the safety-net system, we recognize and seek to collaboratively address social
determinants of health as we proudly serve Alameda County.
The vision of the Alliance is that we will be the most valued and respected managed
care health plan in the state of California.
Our Values (TRACK)
 Teamwork: We participate actively, remove barriers to effective collaboration
and interact as a winning team.
 Respect: We are courteous to others, embrace diversity and strive to create a
positive work environment.
 Accountability: We take ownership of tasks and responsibilities and maintain a
high level of work quality.
 Commitment & Compassion: We collaborate with our providers and community
partners to improve the wellbeing of our members, focus on quality in all we do
and act as good stewards of resources.
 Knowledge & Innovation: We seek to understand and find better ways to help
our members, providers and community partners.

Call the Alliance Provider Services Department Monday – Friday, 8 am – 5 pm at
510.747.4510. Visit online at www.alamedaalliance.org.
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The Provider Manual
This Provider Manual describes your responsibility as a provider to our members, and is
intended as a resource to help you provide them with the best possible care.
The Alliance requires that contracted practitioners, medical groups, providers, hospitals,
ancillary providers, and other non-hospital facilities, together referred to as “Provider” or
“Providers,” fulfill the relevant specified responsibilities described in this Provider
Manual.
If you have any questions about the Alliance, our practices, or our members, please feel
free to contract our Provider Services Department.
Getting Involved
Provider involvement helps us improve services for our members and providers.
WAYS TO PARTICIPATE:
Health Care Quality Committee (HCQC): HCQC meets quarterly. The Alliance
Providers are encouraged to participate in the HCQC and its peer subcommittees.
HCQC and other subcommittee members are paid a stipend. Please call the
Credentialing Department at 510.373.5677 for more information.
Peer Review & Credentialing Committee (PRCC): PRCC meets monthly to review
new provider applications, re-credentialing information, and peer review issues on
contracted providers.
The Alliance Provider Manual: The Alliance communicates with providers through
this manual and periodic updates. Provider suggestions have been incorporated in
this manual. Feedback is always helpful in keeping the manual as up-to-date as
possible. Call the Alliance Provider Services Department at 510.747.4510 with your
ideas and comments.
The Alliance Provider Updates Bulletin: The Alliance periodically distributes
provider letters, memos, and updates with additional information to keep you
informed. If you don’t receive these provider communications, or if you have ideas for
topics that you would like to see covered, please call the Alliance Provider Services
Department at 510.747.4510.
Provider Training Sessions: The Alliance conducts training sessions throughout
the year for providers and their staff. If you or your staff are interested, please call
the Alliance Provider Services Department at 510.747.4510.
Pharmacy & Therapeutics (P&T) Committee: Meets quarterly to review the drug
formulary, and make changes to the authorization review criteria. Please call the
Alliance general Pharmacy line at 510.747.4541 for more information.

Call the Alliance Provider Services Department Monday – Friday, 8 am – 5 pm at
510.747.4510. Visit online at www.alamedaalliance.org.
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Department Phone Number Address Website
Alameda Alliance for Front Desk 1240 South Loop Road www.alamedaalliance.org
Health Phone Number: Alameda, CA 94502
510.747.4500
Toll-Free:
1.877.371.2222
Member Services
Phone Number:
510.747.4567
Toll-Free:
1.877.932.2738
CRS/TTY:
711/1.800.735.2929
Alliance Case & Disease 877.251.9612 1240 South Loop Road www.alamedaalliance.org
Management (CMDM) Alameda, CA 94502
Alliance Compliance 1.855.747.2234 1240 South Loop Road www.alamedaalliance.org
Department Alameda, CA 94502
Alliance Eligibility Line 510.747.4505 1240 South Loop Road www.alamedaalliance.org
Alameda, CA 94502
Alliance Grievance and Phone Number: 1240 South Loop Road To file a Grievance online, members must
Appeals (G&A) 510.747.4567 Alameda, CA 94502 log into the member portal.
Department Go to: www.alamedaalliance.org and
Fax: see log in information.
1.855.891.7258

Call the Alliance Provider Services Department Monday – Friday, 8 am – 5 pm at 510.747.4510. Visit online at
www.alamedaalliance.org.
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Department Phone Number Address Website
Alliance Health Programs 510.747.4577 1240 South Loop Road www.alamedaalliance.org/live- healthy
Alameda, CA 94502
Alliance Member Services Phone Number: Alliance Member www.alamedaalliance.org/contact-us
Department* 510.747.4567 Services
P.O. Box 2818
Toll-Free: Alameda, CA
1.877.932.2738 94501-0818
CRS/TTY:
711/1.800.735.2929
Alliance Provider Services Provider Call Center: 1240 South Loop Road www.alamedalliance.org/providers
Department 510.747.4510 Alameda, CA 94502
Email:
Fax: [email protected]
1.855.891.7257
Alliance Utilization Phone Number: 1240 South Loop Road www.alamedaalliance.org
Management & 510.747.4540 Alameda, CA 94502
Authorizations
Fax:
1.877.747.4507
24-Hour Interpreter Hotline [phone]
(for interpreters by phone)
ACCESS Program 1.800.491.9099 2000 Embarcadero www.acbhcs.org
Alameda County Cove, Suite 400
Behavioral Health Care Oakland, CA 94606
Call the Alliance Provider Services Department Monday – Friday, 8 am – 5 pm at 510.747.4510. Visit online at
www.alamedaalliance.org.
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Department Phone Number Address Website
Services
Clinical Laboratory 1.800.288.8008 Quest Diagnostics www.questdiagnostics.com
Outpatient Services
Dental Services 1.800.322.6384 Denti-Cal www.denti-cal.ca.gov
(Medi-Cal ages 20 &
below) TTY:
1.800.735.2922
Dental Services 1.888.335.8227 Delta Dental www.acgov.org
(Alliance Group Care)
Public Authority:
510.777.4201
Durable Medical 1.800.906.0626 California Home www.chme.org
Equipment Provider Medical Equipment
(CHME)
Mental Health Care 1.855.856.0577 Beacon Health www.beaconhealthstrategies.com
Services Options (Also known
as College Health IPA;
Subcontracted
Behavioral Health
Provider for Outpatient
Mental Health Services)
Call the Alliance Provider Services Department Monday – Friday, 8 am – 5 pm at 510.747.4510. Visit online at
www.alamedaalliance.org.
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